We read with interest the comments and criticisms by the author/s [Citation1] on our recent paper [Citation2]. Reading through the paper, we find more points of agreement than disagreement. We both agree that obesity is bad regardless of the obesity paradox for the prevention of primary cardiovascular disease (CVD). Several major studies involving millions of subjects have demonstrated that obesity is bad [Citation3], and even in metabolically healthy subjects, it is associated with an increased incidence of CVD, heart failure (HF), type 2 diabetes mellitus, and hypertension [Citation4,Citation5]. The obesity paradox is a bad and controversial term, begging for an explanation, and conveys the wrong message to obese people that obesity might not be bad after all. The term of the obesity paradox is so controversial that some authors that have published extensively on obesity recommend its complete abolition and suggest that journals should no longer accept papers about the obesity paradox [Citation6,Citation7]. Regarding the use of body mass index (BMI) for the existence of the obesity paradox, we do not recommend its abolition, but its use in conjunction with other indices of obesity, such as waist circumference (WC) and waist-to-hip ratio (WHR), which provide, in addition to BMI, more information about fat distribution and are simple and easy to do. Therefore, the combination of all three could provide more accurate information about the existence of the obesity paradox as has been demonstrated by other authors [Citation8]. We do not recommend any complicated and research measures to assess obesity. The author/s agree with us that perhaps patients showing the obesity paradox could be more physically fit and that physical activity, exercise, and cardiorespiratory fitness could be, perhaps, responsible for the obesity paradox as has been aptly suggested by Dr Carl Lavie’s group [Citation8–Citation10]. Also, in contrast to mild-to-moderate obesity, the obesity paradox does not occur in patients with excessive or morbid obesity. In addition, the BMI does not provide any information in patients with reduced muscle volume, the so-called ‘sarcopenic obesity,’ which is worse than the other forms of obesity and is associated with increased all-cause mortality [Citation11]. The strange thing about the obesity paradox is that it provides a longer survival in patients with existing CVD and HF, suggesting perhaps that obese patients may have a greater energy reserve that normal-weight patients. However, it should be realized that it is better to prevent the disease than living longer with the disease because this is not a good life [Citation12]. Therefore, it is important that the physicians encourage their patients to maintain a healthy lifestyle with diet and exercise and maintain a normal weight. Finally, to resolve the issue on the use only of the BMI in the obesity paradox, future studies should focus on using all three indices of obesity (BMI, WC, and WHR) to determine the true incidence of the obesity paradox.
Declaration of interest
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
Additional information
Funding
References
- Carbone S, Lavie CJ. An opposing point of view on the obesity paradox. Postgrad Med. 2019 Jun;131(5):333–334.
- Chrysant SG, Chrysant GS. The single use of body mass index for the obesity paradox is misleading and should be used in conjunction with other obesity indices. Postgrad Med. 2019;131(2):96–102.
- Flegal KM, Kit BK, Orpana H, et al. Association of all-cause mortality with overweight and obesity using standard body mass index categories. A systematic review and meta-analysis. JAMA. 2013;309:71–82.
- Bell JA, Kivimaki M, Hamer M. Metbolically healthy obesity and risk of incident type 2 diabetes: a meta-analysis of prospective cohort studies. Obesity Rev. 2014;15:504–515.
- Caleyachetty R, Thomas GN, Toulis KA, et al. Metabolically healthy obese and incident cardiovascular disease events among 3.5 million men and women. J Am Coll Cardiol. 2017;70:1429–1437.
- Flegal KM, Ioanidis JP. The obesity paradox: a misleading term that should be abandoned. Obesity. 2018;26:629–630.
- Peeters A. Journals should no longer accept “obesity paradox” articles. Int J Obes. 2018;42(3):584–585.
- Pandey A, Patel KV, Lavie CJ. Obesity, central adipocity, and fitness: understanding the obesity paradox in the context of other cardiometabolic parameters. Mayo Clin Proc. 2018;93(3):676–678.
- Lacie CJ, Cahalin LP, Chase P. et al. Impact of cardiorespiratory fitness on the obesity paradox in patients with heart failure. Mayo Clin Proc. 2013;88(3):251–258.
- McAuley PA, Keteyian SJ, Brawner CA. et al. Exercise capacity and the obesity paradox in heart failure: the FIT project. Mayo Cin Proc. 2018;93(6):701–708.
- Yamashita M, Kamiya K, Matsunaga A, et al. Prognostic value of sarcopenic obesity estimated by computed tomography in patients with cardiovascular disease and undergoing surgery. J Cardiol. 2019 March 27. DOI:10.1016/J.JJcc 2019.02.010
- Khan SS, Ning H, Wilkins JT, et al. Association of body mass index with lifetime risk of cardiovascular disease and compression of morbidity. JAMA. 2018;3(4):280–287.